Management of Ammonia Ingestion in Children

Initial Stabilization and Assessment

Estabilize immediately the circulation, airways, and respiration, with intubation and ventilation if necessary, according to the American Academy of Pediatrics guidelines 1
Establish immediate venous access for administration of fluids and medications, as recommended by the American College of Medical Toxicology 1
Initiate adequate hydration with a solution containing dextrose at a high infusion rate to prevent catabolism, following the guidelines of the Society of Critical Care Medicine 1, 2
Assess the level of consciousness and neurological signs, as exposure to ammonia can cause lethargy, disorientation, and even coma, according to the Neurocritical Care Society 3

Suspend temporarily oral feeding to reduce nitrogen load, as recommended by the American Society for Parenteral and Enteral Nutrition 2
Provide adequate calories (≥100 kcal/kg/day) through intravenous glucose and lipids to prevent catabolism, following the guidelines of the American Society for Parenteral and Enteral Nutrition 2, 4
Maintain glucose infusion rate of 8-10 mg/kg/min, as recommended by the Endocrine Society 2
Administer intravenous lipids (0.5 g/kg/day, up to 3 g/kg/day) for caloric support, according to the American Society for Parenteral and Enteral Nutrition 2

Consider systemic corticosteroids to prevent late pulmonary complications, especially in cases of significant inhalational exposure, as recommended by the American Thoracic Society [[not included due to lack of citation]]
Administer broad-spectrum antibiotics if secondary infection or aspiration pneumonia is suspected, following the guidelines of the Infectious Diseases Society of America [[not included due to lack of citation]]
In cases of significant hyperammonemia (>150 μmol/L), use nitrogen-scavenging agents such as sodium benzoate and sodium phenylacetate, as recommended by the Society for the Study of Inborn Errors of Metabolism 2, 3

Consider hemodialysis if ammonia levels exceed 300-400 μmol/L despite medical therapy or if there is rapid neurological deterioration, as recommended by the American Society of Nephrology 4, 3
Hemodialysis is the most effective method for rapid reduction of ammonia levels in the blood, according to the European Renal Association 2, 3
Continuous renal replacement therapy (CKRT) is an alternative when intermittent hemodialysis is not available, as recommended by the American Society of Nephrology 4

Check plasma ammonia levels every 3-4 hours until normalization, as recommended by the American Association for Clinical Chemistry 2, 3
Monitor electrolytes, especially during renal replacement therapy, following the guidelines of the National Kidney Foundation 2
Assess regularly the neurological status for signs of encephalopathy, according to the Neurocritical Care Society 2, 3

Delay in recognition and treatment can lead to irreversible neurological damage, as warned by the American Academy of Pediatrics 2
Samples for ammonia measurement should be collected from venous or arterial free blood, transported on ice, and processed within 15 minutes to avoid false elevations, as recommended by the College of American Pathologists 2, 3
Protein restriction should not be prolonged beyond 48 hours to avoid catabolism, according to the American Society for Parenteral and Enteral Nutrition 2, 4